IBD scoring systems. Lara Hart, MD FRCPC 1,2 Talat Bessissow, MD FRCPC 1 Mallory Chavannes, MD FRCPC 3,4

Transcription

1 IBD scoring systems Lara Hart, MD FRCPC 1,2 Talat Bessissow, MD FRCPC 1 Mallory Chavannes, MD FRCPC 3,4 1. McGill University Health Center, Montreal QC; 2. McMaster University Medical Center, Hamilton ON; 3. St-Paul s Hospital, University of BriGsh Columbia, Vancouver, BC; 4. CHU Sainte JusGne, University of Montreal, Montreal QC

2 ObjecFves At the end of this program, par2cipants should be able to DifferenGate between the various IBD scoring systems Understand the uglity of the scoring systems and the grading of severity associated with each score Use the scoring systems in endoscopy reports

3 Name: Dr. Lara Hart Conflict of Interest Disclosure (over the past 24 months) Commercial or Non- Profit Interest Abbvie Relationship Research support

4 Name: Dr. Talat Bessissow Conflict of Interest Disclosure (over the past 24 months) Commercial or Non- Profit Interest Abbvie Janssen Takeda Ferring, Shire, Pendopharm, Merck Pfizer Pentax Relationship Speaker, advisory board, research support Speaker, research support Speaker, advisory board Speaker advisory board Research support

5 Name: Dr. Mallory Chavannes Conflict of Interest Disclosure (over the past 24 months) Commercial or Non- Profit Interest Abbvie Relationship Research support

6 CanMEDS Roles Covered X X Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centered care. Medical Expert is the central physician Role in the CanMEDS Framework and defines the physician s clinical scope of practice.) Communicator (as Communicators, physicians form relationships with patients and their families that facilitate the gathering and sharing of essential information for effective health care.) Collaborator (as Collaborators, physicians work effectively with other health care professionals to provide safe, high-quality, patient-centred care.) X X X Leader (as Leaders, physicians engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.) Health Advocate (as Health Advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change.) Scholar (as Scholars, physicians demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship.) Professional (as Professionals, physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.)

7 1.Molander P, et al. J Crohns Coli/s Villanacci V, et al. World J Gastroenterol 2013;19: Laharie D, et al. Aliment Pharm Therap EvoluFon of treatment targets Histological remission 1,2 Mucosal healing 2,3 Biochemical remission Clinical remission (steroid-free) Clinical response Therapeu?c objec?ve evolve as treatment goals change

8 Symptom-free CRP 36 mg/l

9 Poor correlafon symptoms mucosal lesions Complete lack of correlation between CDAI (primarily symptom-based) and endoscopic inflammation Symptoms and signs of Crohn s are neither sensitive nor specific Modigliani R et al, Gastroenterology 1990

10 CorrelaFon symptoms UC Clinical state Remission Mild moderate Severe Sigmoidoscopic state Normal Mild moderate Histological findings: Degree of inflamma?on None Mild moderate Severe Severe Truelove SC, et al. Br Med J 1956;1:1315 8

11 Mary JY et al. Gut 1989; 30: CD Scoring Systems- CDEIS (1989)

12 CD Scoring Systems- SES-CD (2004) InacGve= 0 2; mild = 3 6; moderate 7 15; severe >16 DefiniGon of MH varies Daperno M et al. GIE 2004; 60(4):

13 Rutgeerts score (1990) Sostegni et al. APT 2003; 17:11-7.

14 CD scoring systems Scoring system Strength Weakness CDEIS SES-CD Rutgeerts score Gold standard Validated ProspecGve study Extensively applied in clinical trials Validated ProspecGve study Simpler than CDEIS Correlated with CDEIS ProspecGve study Extensively applied in clinical trials Strong prognosgc relevance Complexity No definigon of MH No correlagon with CDAI No definigon of MH No correlagon with CDAI Less applied in clinical trials No formal validagon Only in post-operagve ileo-colonic resecgon Daperno M et al. GIE 2004; 60(4):

15 UC Scoring systems Index Validated Variables Strengths Weaknesses Truelove and Wibs Endoscopy Index No Granularity, hyperemia Precedence (first reported index), but no other merit No descrip?on of endoscopic lesions so inter-observer variability is high Baron Index No Bleeding, vascular pabern, friability Easy to use Ulcera?ons not included in score; no defini?on of mucosal healing Powell-Tuck Index No Bleeding Easy to use Ulcera?on not included, no defini?on of mucosal healing Sutherland Index No Friability, bleeding, exuda?on Easy to use, overlap in descrip?ve terms for different levels of ac?vity Subjec?ve, no defini?on of mucosal healing Mayo Clinic Index (endoscopic subscore) No Vascular pabern, erythema, friability, erosions and ulcera?on, bleeding Easy to use, commonly used in clinical trials; overlap in descrip?ve terms used for different levels of ac?vity No validated defini?on of mucosal healing; The term minimal or slight friability is subjec?ve and leads to inconsistent results Rachmilewitz Index No Granula?on, mucosal damage, vascular pabern, vulnerability of mucosa (bleeding) None reported Complex and subjec?ve descrip?ve terms Modified Baron Index No Vascular pabern, granularity, friability, bleeding, ulcera?on Easy to use No validated defini?on of mucosal healing Endoscopic Ac?vity Index No Size of ulcers (4 levels), depth of ulcers (4 levels), redness (3 levels), bleeding (4 levels), mucosal edema (4 levels), mucosal exudate (3 levels) Closely correlated with clinical ac?vity. Comparable to other indices. Useful in severe disease Mabs Index No Granularity, bleeding, edema, ulcera?on Easy to use Ulcera?ve Coli?s Endoscopic Index of Severity Preliminary Vascular pabern (3 levels), bleeding (4 levels), ulcera?on (4 levels) Easy to use; Independent of clinical symptoms, accounts for 88% of varia?on between observers Sensi?vity to change, and mucosal healing remain undefined Walsh A, et al. Gastrointest. Endosc Clin. N. Am. 2014;24:

16 UC Scoring systems- Mayo score (1987) Mayo index Stool frequency Normal 1 2/day > normal 3 4/day > normal 5/day > normal Rectal bleeding None Streaks Obvious Mostly blood Mucosa Normal Mild friability Moderate friability Spontaneous bleeding Physician s global assessment Normal Mild Moderate Severe 0 = inacgve disease; 1= mild disease; 2= moderate disease; 3= severe disease. Mucosal healing = 0 or 1 Schroeder KW, et al. N Engl J Med 1987;317:1625 9

17 UC Scoring systems- UCEIS (2012) Descriptor (score most severe lesions) Likert scale anchor points Defini?on Vascular pabern Bleeding Erosions and ulcers Normal (1) Patchy oblitera?on (2) Obliterated (3) None (1) Mucosal (2) Luminal mild (3) Luminal moderate or severe (4) None (1) Erosions (2) Superficial ulcer (3) Deep ulcer (4) Normal vascular pabern with arborisa?on of capillaries clearly defined, or with blurring or patchy loss of capillary margins Patchy oblitera?on of vascular pabern Complete oblitera?on of vascular pabern No visible blood Some spots or streaks of coagulated blood on the surface of the mucosa ahead of the scope, which can be washed away Some free liquid blood in the lumen Frank blood in the lumen ahead of endoscope or visible oozing from mucosa aner washing intra-luminal blood, or visible oozing from a haemorrhagic mucosa Normal mucosa, no visible erosions or ulcers Tiny ( 5 mm) defects in the mucosa, of a white or yellow colour with a flat edge Larger (>5 mm) defects in the mucosa, which are discrete fibrin-covered ulcers in comparison with erosions, but remain superficial Deeper excavated defects in the mucosa, with a slightly raised edge *Threshold for MH, mild, moderate and severe disease not set Travis SPL, et al. Gut 2012;61:535 42

18 Scoring systems current use and reliability

19 Use of IBD scores within clinical trials (UC) Used for objecgve assessment of endoscopic improvement Interrater agreement poor between site reader and central readers (ICC 0.11 to 0.44) but high between central readers in UC Feagan BG, et al. Gastroenterol 2013;145(1):

20 Use of IBD scores within clinical trials (CD) Beder inter-observer correlagon using SES-CD and CDEIS Rutgeerts P, et al. Gastrointes/nal Endoscopy 2016;83(1):

21 Canadian Survey: Do you see what I see 129 staff physicians 116 treagng adults (90%) 78 from academic centers (60%) 52 performed >750 colonoscopies/year (40%) 38 had >20 years in pracgce (29%) 47 fellows replies 21 were PGY-5 (45%) 13 performed >400 colonoscopies/year (28%) Hart et al, Unpublished data

22 Use of IBD scores in clinical pracfce Staff (n=129) Residents (n=47) All (n=176) Using SES-CD, n (%) 41 (32) 26 (55) 67 (38) Using CDEIS, n (%) 3 (2) 1 (2) 4 (2) Using Mayo, n (%) 114 (88) 42 (89) 156 (89) Comfort using CD score, n (%) 65 (50) 12 (25) 77 (44) Comfort using UC score, n (%) 111 (86) 37 (79) 148 (84) Hart et al, Unpublished data

23 Why are physicians using scores 50% of Fme Staff (n=129) Residents (n=47) All (n=176) Not familiar, n (%) 10 (8) 4 (9) 14 (8) Forget to use, n (%) 11 (9) 2 (4) 13 (7) Rather describe, n (%) 37 (29) 13 (28) 50 (28) Time consuming, n (%) 2 (2) 3 (6) 5 (3) Too complicated, n (%) 9 (7) 4 (9) 13 (7) Not trained, n (%) 1 (1) 3 (6) 4 (2) Hart et al, Unpublished data

24 Cases pracfce using the scoring systems

25 Case 1 (UC) 20yo pagent has had 2 year history of ulceragve coligs. Taking 5ASA. Started experiencing progressively worsening symptoms; now having 8-12 loose bloody bowel movements per day. FC >2100, stool for infecgous workup negagve. CRP 55, Hgb 109, albumin 33. You do colonoscopy and see..

26 How would you describe the colon? - Mucopus - Erythema - Loss of vascular markings - UlceraGons - Edema - Friability How severe is the inflammagon? What mayo endoscopic score would it be?

27 Using the MES MES 3 Schroeder KW, et al. N Engl J Med 1987;317:1625 9

28 Case 2 (UC) 18yoM with UC who has been on infliximab since his diagnosis 2 years ago. Receives 7.5mg/Kg q5 weeks. Symptoms are manageable with 3 semi-formed BM per day and no blood and a CRP = 6. Recent fecal calprotecgn improved from 1800 to 965. Colonoscopy to reassess disease shows this

29 How would you describe the colon? - Erythema - Loss of vascular markings - Mucopus - Granularity - ConGnuous inflammagon How severe is the inflammagon? What mayo endoscopic score would it be?

30 Using the MES MES 2 Schroeder KW, et al. N Engl J Med 1987;317:1625 9

31 Case 3 (CD) 40yo pagent know to have ileocolonic CD for 2 years. On adalimumab monotherapy 40mg q1wk for the past year (no previous use of infliximab). Worsening symptoms of diarrhea and weight loss over the last 6 weeks. CRP 15. FC 700. You scope to reassess disease acgvity and see this

32 How would you describe the colon? How severe is the inflammagon? What SES-CD score would it be? What percent of the surface is ulcerated? What percent of the surface is affected? - Deep ulcers - Linear/serpiginous ulcers - Erythema - Edema - Aphthous ulcers - Patchy inflammagon

33 Using the SES-CD SES-CD 7-8 Daperno M et al. GIE 2004; 60(4):

34 Case 4 CD 40yo pagent known for a 10 year history of ileocolonic Crohn s disease. Compliant with azathioprine therapy and achieving good levels (6TG 330). Worsening symptoms over the past few months. Hgb 90, Plt 713, WBC 4.2, lymphocytes 0.3. CRP 30. FC loose stools per day, with new onset bleeding but maintaining weight/appegte. You scope and find

35 How would you describe the colon? - Deep linear ulcers - Edema - Possible narrowing of the lumen - Scadered aphthous ulcers and mucopus How severe is the inflammagon? What SES-CD score would it be? What percent of the surface is ulcerated? What percent of the surface is affected?

36 Using the SES-CD SES-CD 9-10 Daperno M et al. GIE 2004; 60(4):

37 Case 5 CD 20yo pagent has had 5 years of ileocolonic CD, on infliximab for 2 years, currently on 5mg/kg q6wk. Recent increase in frequency of bowel movements, with occasional diarrhea. Normal bloodwork. FC 335. On colonoscopy, the colon looked like this

38 How would you describe the colon? - Erythema - Aphthous ulcers How severe is the inflammagon? What SES-CD score would it be? What percent of the surface is ulcerated? What percent of the surface is affected?

39 Using the SES-CD SES-CD 4-5 Daperno M et al. GIE 2004; 60(4):

40 Case 6 (post-operafve) 40yo pagent has had 5 years of ileocolonic CD. Presented with obstrucgve symptoms and was found to have stricture at TI. PaGent had an ileocecal resecgon and had a repeat scope to assess anastomosis site

41 Using Rutgeerts score Rutgeerts i1 Sostegni et al. APT 2003; 17:11-7.

42 MES quick cases MES 1 MES 2 MES 0 MES 3

43 SES-CD quick cases SES-CD 0 SES-CD SES-CD 4-6 SES-CD 7-9

44 Using the UCEIS UCEIS 7 Travis SPL, et al. Gut 2012;61:535 42

45 Using the UCEIS UCEIS 3-4 Travis SPL, et al. Gut 2012;61:535 42

46 Using the CDEIS CDEIS Feature Scoring Deep ulceragons 0 = no, 12 = yes Superficial ulceragons 0 = no, 6 = yes Surface involved in disease 1 point per every 10% Surface involved in ulceragons 1 point per every 10% Ulcerated stenosis or non-ulcerated stenosis Add 3 points Mary JY et al. Gut 1989; 30:

47 Using the CDEIS CDEIS Feature Scoring Deep ulceragons 0 = no, 12 = yes Superficial ulceragons 0 = no, 6 = yes Surface involved in disease 1 point per every 10% Surface involved in ulceragons 1 point per every 10% Ulcerated stenosis or non-ulcerated stenosis Add 3 points Mary JY et al. Gut 1989; 30:

48 Using the CDEIS CDEIS 33 Feature Scoring Deep ulceragons 0 = no, 12 = yes Superficial ulceragons 0 = no, 6 = yes Surface involved in disease 1 point per every 10% Surface involved in ulceragons 1 point per every 10% Ulcerated stenosis or non-ulcerated stenosis Add 3 points Mary JY et al. Gut 1989; 30:

49 Resources IGIBD scores app IBDScores app CAG/Abbvie SEEMLI: Standardizing the Endoscopic EvaluaGon of Mucosal Lesions in IBD:

50 Evaluation and Certificate of Attendance Please download the CDDW app to complete the session evaluagon and to receive your cergficate of adendance.